School based cognitive behavioural therapy targeting anxiety in children with autistic spectrum disorder: a quasi-experimental randomised controlled trail incorporating a mixed methods approach
Open accessAbstract
Children with a diagnosis of autism are more likely to experience anxiety than their typically developing peers. Research suggests that Cognitive Behavioural Therapy (CBT) could offer a way to help children with autism manage their anxiety but most evidence is based on clinical trials. This study investigated a school-based CBT programme using a quasi-experimental design incorporating the child and parent versions of the Spence Children's Anxiety Scale (Spence, J Abnorm Psy 106(2):280-297, 1997) and the Coping Scale for Children and Youth (Brodzinsky et al., J Appl Dev Psychol 13:195-214, 1992). Interview data was incorporated to help understand the process of change further. Children in the experimental condition had lower levels of anxiety, maintained at follow-up and changes were found in coping behaviours such as lower behavioural avoidance strategies but increased problem solving strategies at follow-up. Limitations of the research together with future directions are also discussed.
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This finding of good acceptability to participants is consistent with that of other CBT-based interventions with children and adolescents with autism, providing further evidence for the suitability of this approach with young autistic people.
“This finding of good acceptability to participants is consistent with that of other CBT-based interventions with children and adolescents with autism (e.g., Clarke et al., 2016; McConachie et al., 2014), providing further evidence for the suitability of this approach with young autistic people.”
From The design and implementation of a CBT-based intervention for sensory processing difficulties in adolescents on the autism spectrum (2016) · cites this paper as Clarke et al., 2016
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“Unfortunately, Tier 1 programming is rarely reported (Clarke et al. 2017).”
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“The SCAS is widely used as an outcome measure in treatment studies with autistic youth (e.g. Clarke et al., 2017; Luxford et al., 2017).”
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“Several YP described effects of the physical environment , both as facilitators, “ it was quite good doing it in school, ‘ cause we're all comfortable with our surroundings ” (McKeague et al., 2018), and barriers, “ [the room was] really small and it felt cramped ” (Clarke et al., 2017).”
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“…symptoms [18, 19], and a handful of studies have adapted CBT for autistic youth with anxiety for school-based delivery, with encouraging results [20, 21]; however, the long-term viability of such programs is limited, since these studies relied heavily on research personnel to deliver or…”
BackgroundCognitive Behavioral Therapy (CBT) and ASD
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“…emotions, affective instruction, cognitive restructuring, stress management, self-re fl ection or group-re fl ection, and guided practices on new cognitive skills (Clarke et al., 2017; Factor et al., 2019; McGillivray & Evert, 2014; Scarpa & Reyes, 2011; Sofronoff et al., 2007; Weiss et al., 2018).”
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“Session feedback was sought in three studies (Clarke et al., 2017; Grimes, 2015; Kite, 2020), with Kite (2020) discussing the importance of seeking regular feedback in monitoring the intervention.”
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A systematic review of the treatments of anxiety in children with autism spectrum disorder
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“…were used as measures of response for all except for White, Schry 29 utilized CASI-4, Luxford, Hadwin, 33 Conaughton, Donovan, 44 and Clarke, Hill 42 used Spence Children ’ s Anxiety Scale, Child and Parent versions (SCAS-C/P), Guzick, Schneider 16 utilized Clinical Global Impression-severity…”
Assessment and treatment of anxiety in children and adolescents with ASD: a systematic review
Perihan, C., Burke, M. D., Bowman-Perrott, L. J., & Bocanegra, J. O. (2021) · Advances in Autism · doi:10.1108/aia-03-2021-0016 · Cited by 2 · see citing works
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“Results indicated that students who received the CBT intervention in the experimental condition had lower levels of anxiety and increased coping strategies, with results maintaining post intervention (Clarke et al., 2017).”
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“Studies have shown that this drug is most effective when combined with behavioural therapy [47].”
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Perihan, C., Burke, M. D., Bowman-Perrott, L. J., & Gallup, J. L. (2019) · Springer eBooks · doi:10.1007/978-1-4614-6435-8_102461-1 · Cited by 2 · see citing works
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“Clarke et al., (2017) reported reductions in anxiety and behavioral avoidance in a randomized control trial (RCT) of Attwood’s (2004) Exploring Feelings program implemented in a school setting.”
Hayden‐Evans, M., Afsharnejad, B., Lee, E. A. L., Milbourn, B. T., Picen, T., Johnson, M., Bölte, S., & Girdler, S. J. (2025) · BMC Pediatrics · doi:10.1186/s12887-025-05686-6 · Cited by 1 · see citing works
“The school environment presents an opportunity for children to learn and practice new skills in real-word situations, promoting generalis-ability of these skills beyond the clinical context [42].”
Reaven, J., Cosgrove, K. T., Losh, A., Nickles, S., Kerns, C. M., Pickard, K. E., Blakeley‐Smith, A., Hayutin, L. G., Meyer, A. T., Middleton, C., et al. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1569435 · Cited by 1 · see citing works
Uddin, T., Reid, C., Valmaggia, L., Sunthararajah, S., & Hollocks, M. J. (2026) · Research in Autism · doi:10.1016/j.reia.2026.202916 · Cited by 1 · see citing works
Kester, K. R., & Lucyshyn, J. M. (2022) · Medical Research Archives · doi:10.18103/mra.v10i10.3117 · Cited by 1 · see citing works
Linsao, A. W., McKiernan, P. M., & Morgan, S. M. (2023) · Journal of Community Psychology · doi:10.1002/jcop.22994 · Cited by 1 · see citing works
Sturm, A., & Kasari, C. L. (2023) · Issues in clinical child psychology · doi:10.1007/978-3-031-20006-9_9 · Cited by 1 · see citing works
International experience in mental health provision in secondary schools
Bozhkova, E. D., Коновалов, А. А., & Katunova, V. V. (2022) · Revista Amazonia Investiga · doi:10.34069/ai/2022.59.11.12 · Cited by 1 · see citing works
Comorbidity with neurodevelopmental disorders
Jarrett, M. A., Reiner, A., Simmons, G. L., Davis, T. E., & White, S. W. (2023) · Elsevier eBooks · doi:10.1016/b978-0-323-99613-6.00002-8
A new school-based play approach for young children’s wellbeing: evidence from a 14-week study
Choy, S. W.-W., & Guckin, C. M. (2023) · Irish Educational Studies · doi:10.1080/03323315.2023.2261440
“Appendix A included questions for children, parents, and class teachers (adapted from Clarke, Hill, and Charman 2017).”
BackgroundHayutin, L. G., Middleton, C., Yankowitz, L. D., Boles, R. E., Blakeley‐Smith, A., Meyer, A. T., Pickard, K. E., Reyes, N., Stahmer, A. C., & Reaven, J. (2024) · School Mental Health · doi:10.1007/s12310-024-09730-1
“…that CBT for anxiety in autistic youth can be effectively provided in schools; however, most have relied on research teams to deliver the intervention, or pair researchers with school providers to co-facilitate the intervention (Clarke et al., 2017; Ireri et al., 2019; Luxford et al., 2017).”
Sharma, S., Hucker, A., Matthews, T., Grohmann, D., & Laws, K. R. (2021) · Figshare · doi:10.6084/m9.figshare.16725780
A scoping review of interventions to target anxiety in autistic adolescents
Daly, A., & Kieran, A. (2026) · Educational Psychology in Practice · doi:10.1080/02667363.2025.2612357
“Eight studies were consistent in finding reductions in anxiety across multiple raters (Blakeley-Smith et al., 2021; Clarke et al., 2017, de Bruin et al, 2014; Drmic et al., 2017; Luxford et al., 2017, Murphy et al., 2017; Rosen et al., 2022; Sze & Wood, 2008).”
InfluentialJalali, A., Ghasemianrad, M., Khazaie, H., Jalali, R., Chavoshani, F., Khalili, M., & Kazeminia, M. (2026) · SN Comprehensive Clinical Medicine · doi:10.1007/s42399-025-02235-1
Emetophobia: School-Based Intervention Strategies
Corcoran, S., & Ponder, J. M. (2026) · Beyond Behavior · doi:10.1177/10742956261420690
“Providing CBT in school settings is advantageous in that it affords significantly more opportunities to generalize the skills learned in the setting in which they are expected to occur (Clarke et al., 2017).”
Shao, S., Han, D., & Wang, J. (2026) · Research in Autism · doi:10.1016/j.reia.2026.203008
- Authors
- Clarke, C., Hill, V., & Charman, T.
- Affiliations
- Children's Therapy Center (US)
- University College London (GB)
- King's College London (GB)
- Corresponding author
- Clarke, Chris
- Venue
- Journal of Autism and Developmental Disorders
- Published
- 2016-04-30
- Volume
- 47
- Issue
- 12
- Pages
- 3883-3895
- ISSN
- 0162-3257 (ISSN-L)
- 1573-3432
- OpenAlex
- W2344306096
- Cited by
- 59
- References
- 46
- Citations by year
- 2026: 5 · 2025: 5 · 2024: 4 · 2023: 11 · 2022: 7 · 2021: 9 · 2020: 4 · 2019: 7 · 2018: 5 · 2017: 1 · 2016: 1
- FWCI
- 2.98
- Type
- journal article
- Language
- en
- Open access
- green
- kclpure.kcl.ac.uk
- Licence
- other-oa
- www.springer.com/tdm (tdm)
- Locations
- Journal of Autism and Developmental Disorders (publishedVersion)
- PubMed (publishedVersion)
- Research Portal (King's College London) (submittedVersion, other-oa)
- UCL Discovery (University College London) (submittedVersion)
- UEA Digital Repository (University of East Anglia) (submittedVersion)
- Topics
- Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Keywords
- cognitive behavioral therapy, autism spectrum disorder, childhood anxiety, school-based intervention, Spence Children's Anxiety Scale, coping strategies, avoidance behavior, problem solving, change processes
- MeSH terms
- Autism Spectrum Disorder, Adaptation, Psychological, Adolescent, Anxiety, Child, England, Female, Humans, Male, Problem Solving, School Health Services, Cognitive Behavioral Therapy
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